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I am a:*

New Latisse® MD Customer
Returning Latisse® MD Customer

Have you used Latisse® in the past?*

Yes
No

Describe any MEDICAL CONDITIONS related to your EYES including, but not limited to, glaucoma and/or eye infections. If none, please enter "none" in the field below. *

Please list any other MEDICAL CONDITIONS you have. If none, please enter "none" in the field below.*

Please list any MEDICATIONS you are taking, including, but not limited to, prescribed and/or over the counter EYEDROPS. If none, please enter "none" in the field below.*

Please list any ALLERGIES you have to medications. If none, please enter "none" in the field below.*

Have you had an eye exam in the last two years?*

Yes
No

If so, was your eye pressure normal?*

Yes
No, my eye pressure was low
No, my eye pressure was high
N/A

Are you pregnant, breast feeding or planning to become pregnant while taking this medication?*

Yes, I am pregnant, breast feeding, or planning to become pregnant while taking this medication.
No

There are currently no adequate and well-controlled studies of bimatoprost ophthalmic solution 0.03% administration in pregnant and/or nursing women. As such, and to ensure our patients and their children's safety, we will not prescribe Latisse® via the Latisse.MD website to pregnant or nursing mothers. If you are pregnant or breast feeding we recommend using Latisse® only under the close supervision of your OB/GYN.

Are you a Brilliant Distinctions® member? Brilliant Distinctions® is a FREE savings program by Allergan, the manufacturer of Latisse®. Learn more and sign up at www.BrilliantDistinctions.com! *

Yes
No

Release of Liability: I accept full responsibility for any and all adverse side effects that may occur if I choose to use Latisse®. I hereby release Allergan, Latisse.MD and its medical director of any and all liability in connection with using this product. *

I Agree

I watched the "How To Apply" video available at http://www.latisse.md/latisse/how-to-apply-latisse/. I understand how to apply Latisse ® properly, and I do not require further instructions on how to apply Latisse ®.*

I Agree

I waive the option to be seen in person for medical evaluation and hereby certify that all of the information I have provided is true and correct. I understand that Latisse® is a prescription product and, under federal law, cannot be returned for any reason. *

I Agree

How did you hear about us?*

Electronic Signature*

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Your electronic signature above is your signed acceptance that all information submitted is true and correct to the best of your knowledge and that you accept USPS's delivery confirmation as proof of Latisse® delivery to you unless you purchase insurance when placing your order.

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Medical History Form